Open Forum Infectious Diseases

MAJOR ARTICLE

The Increase in Hospitalizations for Urinary Tract

Infections and the Associated Costs in the United States,
1998–2011
Jacob E. Simmering,1 Fan Tang,2 Joseph E. Cavanaugh,3 Linnea A. Polgreen,4 and Philip M. Polgreen5
1
University of Iowa Health Venture’s Signal Center for Health Innovation, Iowa City; 2Genentech, San Francisco, California; 3Biostatistics, College of Public Health, University of Iowa, Iowa City;
4
Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City; 5Internal Medicine, College of Medicine, and Epidemiology, College of Public Health, University of Iowa,
University of Iowa Health Venture’s Signal Center for Health Innovation, Iowa City

Background.  Outpatient therapies for urinary tract infections (UTIs) are becoming limited due to antimicrobial resistance. The
purpose of this paper is to report how the incidence of hospitalizations for UTIs have varied over time in both men and women
and across age groups. We also explore how the severity for UTI hospitalizations has changed and describe the seasonality of UTI
hospitalizations.
Methods.  Using the Nationwide Inpatient Sample, we compute a time-series of UTI incidence and subdivide the series by age
and sex. We fit a collection of time-series models to explore how the trend and seasonal intensity varies by age and sex. We modeled
changes in severity using regression with available confounders.
Results.  In 2011, there were approximately 400 000 hospitalizations for UTIs with an estimated cost of $2.8 billion. Incidence
increased by 52% between 1998 and 2011. The rate of increase was larger among both women and older patients. We found that the
seasonal intensity (summer peaks and winter troughs) increased over time among women while decreasing among men. For both
men and women, seasonality decreased with advancing age. Relative to controls and adjusted for demographics, we found that costs
among UTI patients grew more slowly, patients left the hospital earlier, and patients had lower odds of death.
Conclusions.  Incidence of UTI hospitalization is increasing and is seasonal, peaking in the summer. However, the severity of UTI
admissions seems to be decreasing, indicating that patients previously treated as outpatients may now be admitted to the hospital
due to increasing antimicrobial resistance.
Keywords.  healthcare costs; seasonality; time series; trends; urinary tract infections.

Urinary tract infections (UTIs) are among the most common
of all bacterial infections [1]. Half of all women experience
at least 1 UTI by the age of 35 [2], and approximately 20% of
women between the ages of 18 and 24 have a UTI annually [3,
4]. Urinary tract infections are a common reason for healthcare
visits. In the United States, UTIs result in an estimated 7 million
office visits, 1 million emergency department visits, and over
100 000 hospitalizations with an associated annual cost of $1.6
billion [2, 5, 6].
The majority of UTIs are treated on an outpatient basis [7].
However, resistance to first-line oral antimicrobials that are used
to treat UTIs is increasing [4, 8–14], and this resistance com-
plicates outpatient treatment approaches: indeed, increasing
Received 7 October 2016; editorial decision 29 December 2016; accepted 27 January 2017.
Correspondence: P. M. Polgreen, MD, MPH, Department of Internal Medicine, Carver College
of Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242 (philip-polgreen@uiowa.
edu).
Open Forum Infectious Diseases®
© The Author 2017. Published by Oxford University Press on behalf of Infectious Diseases
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DOI: 10.1093/ofid/ofw281
antimicrobial resistance may have reduced the efficacy of tradi-
tional outpatient treatments [7, 14, 15]. As the number of anti-
microbials resistant to outpatient therapies has risen, the number
of hospitalizations for UTIs has also grown. Between 2000 and
2009, hospitalizations for UTIs increased dramatically [16].
However, it is not known how such an increase in hospitalizations
has affected the estimates of healthcare costs attributable to UTIs.
Furthermore, it is not clear what subpopulations of patients are
driving this growth in incidence: the epidemiology of UTIs dif-
fers between men and women and younger and older patients. In
addition, although the incidence of UTIs appears to be seasonal
[17–21], it is not clear how seasonality affects hospitalizations for
UTIs, especially with respect to different populations of patients.
The purpose of this study is to describe the trends and sea-
sonal patterns in the incidence of UTI hospitalizations by age
group and sex. In addition, we describe trends in length of stay,
inpatient mortality, and healthcare costs for hospitalizations
associated with UTIs.
METHODS
Data Source and Case Definition
Hospitalization data were obtained through the Agency for
Healthcare Research and Quality Nationwide Inpatient Sample

Increase in UTI Incidence and Costs  •  OFID • 1

(NIS) for the years 1998 to 2011. The NIS contains a 20% strat-
ified sample of all hospitals in the United States. Each record
represents a single hospitalization that includes diagnoses, pro-
cedures, demographic, and other information about the patient.
Cases were defined as any inpatient stay with a primary diagno-
sis International Classification of Diseases, Ninth Revision (ICD-
9) code of 599.0 (“Urinary tract infection, site not specified”).
We excluded records for patients under 18 years of age or that
did not include values for month, year, age, and patient sex.
Case counts were normalized to incidence rates with the mid-
year population estimates from the Census Bureau by each spe-
cific combination of sex and age category. Age categories were
defined as 18–29, 30–39, 40–49, 50–59, 60–69, 70–79, and over
90 years old. To facilitate comparisons among the groups, the
incidence in some analyses was converted to age-sex-specific
Z-scores (Z = (observation – mean)/standard deviation).
Statistical Analysis
Trend Estimation
An autoregressive moving average (ARMA) model with a sea-
sonal autoregressive component of order 1 was used to charac-
terize the data. A linear trend was incorporated as an exogenous
regressor in the ARIMA model to account for the increase in
UTI cases. Based on the ARMA framework, we can estimate the
trend effect while simultaneously controlling for the temporal
correlation inherent in time-series data. A separate model was
fit for each combination of sex and age (eg, males 18–29, males
30–39…), where the standardized incidence was regressed on
a year index (year  +  (month  –  1)/12) and the month of the
patient’s discharge. The year variable accounts for long-term
changes over time, and the month variable captures seasonal-
ity—annual periodicities as reflected in changes by month.
Seasonal Estimation
To further examine UTI seasonality, we detrended the series:
a linear trend was fit to each of the subseries described above,
and the residuals were obtained. The resulting residuals are a
series that has a constant mean (no trend) but retains the sea-
sonal fluctuations. For each series, we computed the yearly
maximum, minimum, and range observed in these residuals.
We also computed the mean patient age within each of the age
groups used to create the series. We stratified the resulting data
by sex. We estimated the effects of increasing age and increas-
ing year by regressing the observed maximum, minimum, and
range on the mean age and the year with separate models for
men and women.
Severity Estimation
Next, we consider length of stay, inpatient mortality, and
costs for UTI and non-UTI admissions. We used these meas-
ures of severity as opposed to an index such as the Charlson
or Elixhauser comorbidity coding systems due to concerns
about the lack of time invariance of the comorbidity systems.
2 • OFID • Simmering et al
Specifically, changes over time would have affected cases and
controls differently. In contrast, length of stay, mortality, and
costs (after adjustment for inflation) exist on a standard scale
that does not vary over time, and any changes would affect cases
and controls in the same way. We used data from 100% of UTI
cases, but we only retained data on a randomly selected 10%
subsample of controls to reduce the computational demands of
model fitting. Because the 10% subsample is approximately 7
times larger than the number of UTI cases, there is little effect
of this sampling on our estimation. We excluded any of the
cases or controls that had a labor and delivery diagnosis code
on their record (ICD 9 codes: 650, 651, 652, 669.5, 669.6, or
669.7), to reduce confounding by these stays in young women.
We only considered length of stay in cases in which the patient
was discharged alive to avoid truncation due to death. Total
charges were converted to total cost using the Healthcare Cost
and Utilization Project (HCUP)-provided cost-to-charge ratios.
When possible, we used the all-payer hospital-specific ratio.
If the hospital-specific ratio was not reported, we used the
group-average all-payer ratio. These ratios are only available for
years 2001–2011. After conversion to total costs, we applied the
Consumer Price Index for Medical Care [22] to convert all dol-
lar amounts to constant December 2011 dollars.
We estimate changes in length of stay, mortality, and costs
using traditional linear regression or logistic regression models,
as appropriate. We regressed each outcome on the patient age (an
indicator for each decade), sex, number of procedures performed
during the stay, month of year, an indicator for UTI as primary
diagnosis, the year, and the interaction between year and the UTI
indicator. The primary coefficient of interest is on this interaction
term: it reflects the slope difference between the linear trend of
non-UTI and UTI patients. For the regression parameter esti-
mates, we used heteroskedastic-consistent standard errors.
Sensitivity Analysis
Because it is possible that some of the change in incidence of
UTIs could have been associated with changes in coding or
diagnostic approaches, as a sensitivity analysis, we considered
trends in incidence for pyelonephritis (ICD-9-CM codes of 590.
xx) relative to trends for UTIs. Pyelonephritis is a more severe
diagnosis, and regardless of antimicrobial resistance patters of
the causative agent, it is more likely to lead to hospitalization
than the diagnosis of an UTI. Thus, we computed monthly
incidence series for pyelonephritis and UTIs and estimated the
trend using the ARMA framework explained above.
RESULTS
For the years 1998 to 2011, there were 108 672 713 hospital
admissions in the NIS. Of these, 960 516 were for UTIs in
adults. The data required to construct the time series (age, sex,
admission year, and month) were present on 860 870 of these
records. Somewhat smaller samples were used for the severity
models due to the additional variables required (eg, length of tract infections peak in the summer months and the nadir
stay, mortality) (sample sizes are reported with the regressions). occurs during the winter. The incidence of admissions for UTIs
exhibits a stronger seasonal effect for women than for men.
Summary Statistics
Seasonality is most pronounced among younger patients, and it
Weighted summary statistics of the sample are included in
diminishes with advancing age. Among women, for each year of
Table 1. Between 1998 and 2011, the number of UTI admissions
age there was a decrease of 2.6% of a standard deviation in the
increased from 264 404 (12.9 per 10 000 people) to 436 635 (18.4
range of the seasonal intensity. Among men, for each year of age
per 10 000 people). The majority of the increase in admissions
there was a decrease of 1.0% of a standard deviation. During our
occurred among women (67.7% in 1998, 71.4% in 2011). The
study period, the seasonal intensity changed. Among women,
mean age of UTI patients with a primary diagnosis of a UTI
the seasonality increased: the incidence of UTIs for women at
increased from 73.2 to 74.7 years. Mean length of stay decreased
the beginning of our sample was less seasonal than at the end. In
from 5.29 to 4.24 days. For UTI hospitalizations, average real total
contrast, among men, the seasonality diminished. Specifically,
costs increased from $3368 to $6425 between 2001 and 2011. The
with each passing year between 1998 and 2011, the average
20th and 80th percentiles of costs in 2011 were $3113 and $8409,
seasonal intensity increased by 3.0% of a standard deviation in
respectively. The median real total costs increased from $2365 to
women and decreased by 4.5% of a standard deviation in men.
$5019. A plot of total charges over time is shown in Figure 1.
Trend Estimation Severity Estimation

Incidence of hospital admissions for UTIs increased in both Length of stay decreased in both UTI and non-UTI hospi-
men and women of all ages (Table  2). The number of cases talizations. However, in a model adjusting for age (grouped by
increased by 76% over the study period, and incidence (pop- decade), sex, year, month of year, number of procedures, and a
ulation adjusted) increased by 52%. Incidence rates acceler- primary diagnosis of an UTI, we found that the length of stay
ated with advancing age: the growth rate for 18- to 29-year-old decreased faster for patients with a primary diagnosis of an UTI
women was 7.9% of a standard deviation per year, whereas the (Table 4). Specifically, a non-UTI patient stayed an average of
growth rate for 80- to 89-year-old women was 23.1%. Although 13.1 (P < .0001) fewer hours in 2011 compared with 1998; how-
UTI incidence was rising for all sex and age groups, the aver- ever, UTI patients stayed an average of 27.7 (P < .0001) fewer
age rate of increase for women was approximately twice the rate hours—a difference of 14.6 hours (P < .0001).
of increase in men. For example, the rate of increase for 50- to Inpatient mortality decreased substantially between 1998
59-year-old men was 9.8% of a standard deviation per year and and 2011 (Table 4). In general, the odds of inpatient death for
for 50- to 59-year-old women, 19.2%. non-UTI patients decreased by 3% per year. Urinary tract infec-
tion patients, on the other hand, observed an extra 5% (odds
Seasonal Estimation
ratio, 0.95; 95% condidence interval [CI], .94–.95) reduction in
The incidence of UTI hospitalizations is highly seasonal
the odds of death per year for a total of 8% decrease in the odds
and our seasonality findings are reported in Table  3. Urinary
of death per year for UTI patients. Thus, for non-UTI patients,
their odds of death were 35% lower in 2011 than in 1998. In
contrast, for UTI patients, their odds of death were 68% lower
Table  1.  Weighted Baseline Characteristics of UTI Admissions in NIS,
1998–2011 in 2011 than in 1998.
Costs increased for all patients between 1998 and 2011
Variable Name Count/Mean Percent/SD (Table 4). Among non-UTI patients, there was an average
Age 74.03 16.62 yearly increase of $577 (P < .0001). In contrast, UTI patients
Female 2 935 344 69.05% had yearly increases of $317, a difference of $259 (P < .0001)
Race
per year.
 White 2 454 310 74.90%
In 2011, more than 436 437 patients were admitted with a
 Black 424 712 12.96%
 Hispanic 245 948 7.51% primary diagnosis of UTI. These hospitalizations resulted in
 Asian 62 150 1.90% charges of $9.7 billion and a real total cost of $2.8 billion for
  Native American 16 535 0.50% these UTI admissions. The mean real cost per case has increased
 Other 73 252 2.24% by 90.8% and non-UTI mean real cost has increased by more
Length-of-Stay 4.77 5.11
than 123.0% between 2001 and 2011.
Died 74 480 1.75%
Total Charges Sensitivity Analysis
 Mean 13 671 18 940
The incidence rate for pyelonephritis was 4.7 cases per 10 000
 Median 8682
Number of Procedures 0.50 1.09
people in 1998, and it increased by 2.7% to 4.8 cases per 10 000
people in 2011. Monthly incidence is shown in Figure 2. Our
Abbreviations: NIS, nationwide inpatient sample; SD, standard deviation; UTI, urinary tract
infection. regression analysis showed the monthly incidence increased by

Increase in UTI Incidence and Costs  •  OFID • 3

 Number of UTI Cases / Month
25000

20000

15000

10000

5000 Gender
Men
Total Cost (Millons of 2011 Dollars) / Month
160 Women

120

80

40

2000 2004 2008 2012

Figure 1.  Urinary tract infection (UTI) incidence and total cost of hospitalizations by sex, 1998–2011. Incidence is the number of cases per 10 000 people in the community
by sex, and real total costs are converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratio and are normalized to constant December 2011 dollars.
Solid lines denote the male series, whereas dotted lines represent the female series.

0.002 more cases per 10 000 people every year (95% CI, −.001 to
.005). This compares to the 42.6% increase in incidence for UTIs
between 1998 and 2011, and our regression analysis showed an
increase in the monthly incidence of UTIs of 0.04 more cases
per 10 000 people every year (95% CI, .028–.044).
DISCUSSION
We found a dramatic increase in the incidence of hospitaliza-
tions attributable to UTIs from 1998 to 2011: cases increased
by 76% and incidence increased by 52%. The greatest increase
in the number of hospitalizations for UTIs occurred among
women, which is not surprising. Although UTIs are most
common in younger women, our results demonstrated that
most of the increase in UTI hospitalizations occurred among
older women (eg, patients older than 70). Urinary tract infec-
tion hospitalizations also increased for men, especially among
older men. These dramatic changes in incidence of UTI hos-
pitalizations that we report highlight the need to re-estimate
costs attributable to UTIs. An average hospitalization with a
primary diagnosis of UTI cost $3368 in 2001 and $6424 in
2011 (constant December 2011 dollars). The 436 437 cases
hospitalized in 2011 resulted in a total cost of $2.8 billion in
healthcare cost.
These increases in incidence were only observed among UTIs.
The incidence of pyelonephritis remained relatively flat between
1998 and 2011. In addition, the rate of growth over time in pye-
lonephritis incidence was not statistically significantly different
from zero (0.002 [95% CI, −.001 to .005] higher monthly inci-
dence per 10 000 people), whereas UTI incidence was increas-
ing (0.04 [95% CI, .028–.044] higher monthly incidence per
10 000 people every year). Assuming that patients with pyelo-
nephritis are more likely to be hospitalized than patients with
UTIs because of their more severe symptoms, regardless of the
resistance of the causative pathogen, we believe that these find-
ings are consistent with our theory that antimicrobial resistance
was driving some of the increase in incidence in hospitaliza-
tions for patients with a primary diagnosis of an UTI between
1998 and 2011. The relatively faster growth in incidence for

Table  2.  Yearly Trend Estimates From ARMA Models Expressed as the Percentage of a Standard Deviation Increase per Year in UTI Hospitalization
Incidence

Age Group Trend in Men Trend in Men, Standard Error Trend in Women Trend in Women, Standard Error

18–29 6.8% 2.1% 7.9% 3.0%

30–39 2.2% 2.5% 14.6% 2.4%
40–49 6.9% 2.4% 17.1% 2.2%
50–59 9.8% 2.9% 19.2% 1.9%
60–69 6.8% 3.4% 19.7% 2.0%
70–79 12.3% 3.2% 22.4% 1.4%
80–89 14.4% 2.6% 23.1% 1.6%
90+ 12.3% 2.4% 21.4% 1.7%

Abbreviations: ARMA, autoregressive moving average; UTI, urinary tract infection.

4 • OFID • Simmering et al
Table 3.  Effects of Age and Admission Year on Seasonal Intensity of UTI Hospitalization Incidence in Men and Women

Range Minimum Maximum

Effect in Men
Variable Name Effect in Men (SD) Effect in Women (SD) (SD) Effect in Women (SD) Effect in Men (SD) Effect in Women (SD)
† ‡
Patient age −0.010 (0.003)* −0.026 (0.002)* 0.004 (0.002) 0.012 (0.002)* −0.007 (0.003) −0.014 (0.001)*
Admission year −0.045 (0.015)‡ 0.030 (0.010)‡ 0.024 (0.011)§ −0.015 (0.009)† −0.021 (0.014) 0.015 (0.008)†
R2 0.177 0.689 0.072 0.388 0.080 0.471

Abbreviations: SD, standard deviation; UTI, urinary tract infection.

*P < .001.
†
P < .1.
‡
P < .01.
§
P < .05.  

UTIs compared with pyelonephritis is also suggestive of anti-
microbial resistance as a driver of the dramatic increase in the
incidence of hospitalizations for UTIs rather than changes in
coding or changes in diagnostic practices.
Our study period coincided with reports of increases in anti-
microbial resistance for agents commonly used to treat UTIs
[8, 12–14, 16]. Thus, the increase in incidence of admissions we
report is most likely associated with the inability to treat UTIs
in outpatient settings due to increased resistance. If some of
the increase in incidence in admissions was driven by patients
who would have otherwise been treated as an outpatient, we
would expect to see a trend toward the admission of less-severe
patients, ie, patients who were only admitted for treatment with
intravenous (IV) antimicrobials. Indeed, in terms of severity, we
found that the patients admitted at the beginning of our study
period differed from those at the end. Specifically, compared
with controls, costs grew at a 45% slower annual rate for UTI
patients, length of stay fell 110% faster for UTI patients, and the
odds of death for UTI patients fell at a 105% faster rate. We posit
that these less severe patients represent patients who would
have previously been treated as outpatients with oral antimi-
crobial agents.
The dramatic increase in hospitalizations for UTIs sug-
gests the need for oral antibiotics or IV treatments convenient
to administer in outpatient settings that are effective against
uropathogens resistant to first-line antimicrobial treatments.
Converting only a small fraction of patients from inpatient to
outpatient treatment would lead to a large number of patients
being able to avoid a hospitalization, given that the median
UTI hospitalization costs $4500, whereas the cost for outpa-
tient treatment is significantly less expensive. Shifting patients
from inpatient admissions to outpatient treatment could lead
to considerable cost savings. In lieu of new oral antibiotics,
innovative approaches to provide IV antibiotic therapy at
home or in outpatient settings provides alternative cost-sav-
ing approaches; however, payer barriers remain an important
limitation [23].
For both men and women, the annual rate of growth in inci-
dence of admissions for UTIs increased with age. For the oldest
men in our study population, the UTI rate increased at twice
the rate of the youngest men. For the oldest women, the UTI
rate increased at almost 3 times the rate of the youngest women.
Thus, older patients seem to be disproportionally contributing
to the increase in hospitalizations. If the increase in incidence of
admissions for UTI is being driven at least in part by antimicro-
bial resistance, it follows that older patients are more likely to be
affected, given that older patients are more likely to have contact
with the healthcare system and are more likely to be exposed
to multidrug-resistant organisms. However, given that we did
observe an increase in admissions among women of all ages, as

Table 4.  Adjusted Changes in Severity Measures for Control and UTI Patients per Year Between 1998 and 2011a 

Variable Name Change in Controls Change in UTI Patients Difference (SD) Difference as Percentage

Cost (dollars) 576.71 317.24 −259.47 (2.64)* −45%

(n = 6 374 024)
Length-of-stay (hours) −0.936 −1.968 −1.032 (0.024)* +10%
(n = 8 517 901)
Inpatient death 0.97 0.92 0.95 (95% CI, .94–.95)* −5%
(n = 8 734 469)

Abbreviations: CI, confidence interval; SD, standard deviation; UTI, urinary tract infections. 
a
Note that the “change in UTI patients” column is simply the combination of the “change in controls” and “difference” columns (addition for linear models, multiplication for the odds ratios).
*P < .0001.

Increase in UTI Incidence and Costs  •  OFID • 5

 Monthly Incidence per 10,000 people
1.2
0.8
0.4
2000
Figure 2.  Urinary tract infection (UTI) and pyelonephritis incidence, 1998–2011. Incidence is the number of cases per 10 000 people by month.
multidrug resistance spreads, we may see a further increase in
hospitalizations among younger women.
We observed a strong pattern of seasonality for UTI hospi-
talizations among both men and women of all ages: UTI inci-
dence increases in the summer and decreases in the winter.
Reports of seasonality have mostly been restricted to single
centers [17, 18]. However, Internet search terms for UTI are
seasonal in countries around the world [24]. Also of note, we
found that the changes in the degree of seasonality vary by sex.
During our study period, the seasonality of hospitalizations for
UTIs decreased with age for men and women: younger men
and women experience more seasonality than older men and
women. However, over time, the seasonal range increased for
women and decreased for men: specifically, for each year of
our study period, UTIs became more seasonal for women and
less seasonal for men. Although the differences in risk factors
for and epidemiology of UTIs between men and women are
well known [7, 25, 26], our findings suggest additional differ-
ences, highlighting the need to think about different preventive
approaches for men and women. Prevention approaches also
may need to differ by age group.
Although it is unclear why the incidence for UTIs is seasonal,
weather has been associated with the seasonality of several dis-
eases [20, 27–30]. It is noteworthy to mention that blood stream
infections with Gram-negative organisms are seasonal and are
associated in some cases with higher temperatures [19, 21, 31,
32], and most of these blood stream infections could have orig-
inated as UTIs. Further exploration of the seasonality of UTIs
by, for example, adding weather data, may lead to better under-
standing of the cause of this seasonality of UTIs.
Our study has limitations. First, we exclusively used adminis-
trative data and did not have medication or microbiology data,
6 • OFID • Simmering et al
Diagnosis
Pyelonephritis
UTI
2005 2010
Year
and thus we could not directly incorporate information regard-
ing therapies or antimicrobial drug resistance. In addition, we
were unable to review charts to validate the assignment of diag-
nostic codes. Second, in our database, we only observed events
from inpatient admissions and did not observe outpatient UTI
incidence, and the majority of patients were treated on an out-
patient basis; thus, our study was focused only on more severe
or difficult-to-treat cases. Third, our data source did not include
a unique identifier to link visits over time. Thus, we could not
identify patients first treated as outpatients and later admitted
to the hospital for UTIs, nor could we investigate the incidence
among patients with a history of recurrent UTI admissions.
Fourth, the decreases in length of stay that we observed may
have beeen due to improvements in treatment that occurred
during the study period.
Despite our limitations, we show that the incidence of admis-
sions for UTIs have increased dramatically, especially among
older patients and women. We also show that patients admit-
ted for UTIs, on average, appear to be relatively less severe than
in prior years. Our results are consistent with what we would
expect to find from increasing antimicrobial resistance, ie,
increasing rates of hospitalization, increasing total cost, and
decreasing average severity among patients admitted with a pri-
mary diagnosis of an UTI. Although, our results provide evi-
dence that antimicrobial resistance may be driving healthcare
costs, future studies with antimicrobial data at the patient level
are needed to confirm our findings. 
CONCLUSIONS
Finally, our results demonstrate the need for (1) new oral or
single-dose antimicrobial agents that can administered in out-
patient settings, (2) focused stewardship efforts on patients with
UTIs, and (3) innovative approaches to treat UTI patients with
resistant pathogens on an outpatient basis. Reducing hospitali-
zations due to resistant organisms may represent “low-hanging
fruit” in an effort to control hospitalization costs and prevent
hospitalizations.
Acknowledgments
Financial support.  This work was funded by the National Heart, Lung
and Blood Institute at the National Institutes of Health (Grant number
K25HL 122305; to L. A. P.), the University of Iowa Health Ventures’ Signal
Center (to P.  M. P.), and a dissertation fellowship from the University of
Iowa College of Pharmacy (to J. E. S.).
Potential conflicts of interest.  All authors: No reported conflicts.
The authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the con-
tent of the manuscript have been disclosed.
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